Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment

Trial protocol for evaluating sub-ulcer foam sclerotherapy as an adjunct to conventional endovenous treatment in patients with venous leg ulcers: The FINNULCER multicenter randomized controlled trial

BackgroundVenous leg ulcers (VLUs) affect approximately 1% of the adult population and incur significant morbidity and healthcare costs. Endovenous interventions, such as endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS), have shown benefits in treating venous insufficiency in patients with VLUs. However, the effect of specifically targeting the sub-ulcer venous plexus with foam sclerotherapy remains poorly understood.ObjectiveThe FINNULCER trial is investigating the addition of sub-ulcer foam sclerotherapy to conventional endovenous treatment (EVLA + UGFS) for managing superficial venous insufficiency in patients with VLUs. The primary aim is to evaluate the effect of sub-ulcer foam sclerotherapy in promoting ulcer healing.MethodsPatients with VLUs are being screened at four vascular surgery units in Finland. Eligible participants who provide informed consent are randomized into the study group to receive sub-ulcer foam sclerotherapy + EVLA + UGFS or into the control group to receive EVLA + UGFS. The primary outcome is the time to ulcer healing during 1 year of follow-up from randomization. Secondary outcomes include quality of life assessments and procedure-related outcomes.Trial registrationClinicalTrials.gov (NCT04737941).

The Prevalence of Contact Allergies for Wound Dressings in Patients With Diabetic Foot Ulcers (PAID Study), an Observational Prospective Trial

This investigator initiated prospective observational study investigates the prevalence of contact allergies in patients with a Diabetic Foot Ulcer (DFU). Patients with a DFU received a combined PATCH-test (a test used to investigate the origin of an allergic reaction on the skin) at the upper back, with the European baseline series, the European leg ulcer series, and local used material for leg ulcers. A total of 108 patients with DFU were included of which 86 (79.6%) were male, and 9 (8.3%) and 99 (91.7%) patients had Type 1 and Type 2 diabetes, respectively. Twenty-one patients had a sensitization in the standard series, 30 patients in the leg ulcer series, and 11 patients in both series. Two patients had a positive reaction for one of the local used materials. Most frequent sensitizations were found for Perubalsem (N = 6) and Fragrance-Mix II (N = 4) in the standard series. A sensitization for Povidone-Iodine (N = 20) was most frequently seen in the leg ulcer series. In the local used materials a sensitization for silver sulfadiazine (N = 1) and cutimed-gel (n = 1) were seen. In conclusion, this study provides novel information about sensitizations in patients with DFU, but more research is needed to demonstrate the relationship between allergic reactions and delayed wound healing. The study protocol was registered in www.clinicaltrials.gov (NCT04085705, PAID study).

Efficacy of Ultrasound-Guided Foam Sclerotherapy in the Healing of Venous Leg Ulcers

BACKGROUND

Ultrasound-guided foam sclerotherapy (UGFS) for treating the refluxing venous network beneath and in the vicinity of venous leg ulcers (VLU) has been widely used.

OBJECTIVE

This trial aimed to assess the efficacy and safety of UGFS for treating VLU (ISRCTN18090073).

METHODS

This study is a multi-center randomized controlled trial. Consenting eligible participants were randomized into two groups: Group A received UGFS for the distal refluxing network of veins, e.g. ulcer bed venous plexus, in addition to standard care, and Group B received standard care alone. Standard care included compression therapy, wound care, ablation of superficial reflux and recanalization of proximal deep venous obstruction when appropriate. Patients were followed weekly until complete ulcer healing was achieved. All participants will be followed up for at least 12 months from the point of randomization to allow calculation of total ulcer free days during the study period, to assess for recurrence of ulceration from the time of ulcer healing, and quality of life measures. The primary outcome was the time to ulcer healing. Secondary outcomes were the rate of ulcer healing, venous clinical severity score (VCSS) and patient-reported health-related quality of life.

RESULTS

The study was terminated early for efficacy at the planned interim analysis when half the number of patients completed follow up. A total of 71 patients, 6 with bilateral VLU, were recruited. After accounting for dropouts and losses to follow up, 65 VLU were available for analysis. Both groups were similar at baseline regarding demographic factors, risk factors, history of deep vein thrombosis, previous venous interventions, and ulcer size. The time to complete ulcer healing was significantly shorter in Group A who received UGFS, as compared to Group B who did not receive UGFS (median 35 days, IQR 22 vs median 56 days, IQR 58; p=0.008). Additionally, more ulcers achieved complete healing within 3 months in Group A compared to Group B (28/29 [97%] vs 27/36 [75%]; p=0.01). Multivariate regression analysis showed a significant effect of UGFS on healing time (p=0.004). Group A showed a significantly more rapid reduction in ulcer size (p<0.0001). There was a significant improvement in VCSS after treatment in both Groups A and B (p<0.0001).

CONCLUSION

While both groups benefited from standard care for treating VLU, the addition of UGFS significantly improved treatment outcomes. UGFS accelerated the healing process, resulting in a shorter time to complete ulcer healing and a higher rate of ulcers achieving complete healing within three months. These findings suggest that UGFS is a valuable adjunctive treatment for VLU, enhancing the efficacy of standard care protocols.

Assessing the Safety, Tolerability and Efficacy of Cell-Free Amniotic Fluid in the Treatment of Non-Healing Venous Ulcers: Initial Experience From a Prospective, Multicenter, Phase II Study

Non-healing venous leg ulcers represent a significant healthcare problem that accounts for about $32 billion of spending in the US alone. Consequently, novel treatment strategies represent a major unmet need. The current study (part one of Phase II study [NCT04647240]) assesses the safety, tolerability and efficacy of the use of cell-free human amniotic fluid in treating venous leg ulcers that did not heal following the correction of venous reflux. Patients received cell-free amniotic fluid injections in and around the wound either weekly or biweekly over 12 weeks. Primary outcomes included safety, tolerability and efficacy assessed by complete wound closure, wound area reduction and pain reduction. Eleven patients met enrollment eligibility, and nine completed the study. Five patients achieved complete wound closure by week 12. The average percent reduction in wound area was 83.7%, and pain scores were significantly lower by the study endpoint. No difference was observed in wound healing rates between weekly or biweekly treatment, but bi-weekly treatment was associated with nominally faster recovery. Patients tolerated the treatment, and no side effects were reported. These results indicate that cell-free amniotic fluid injection is a feasible, safe and effective treatment for non-healing venous leg ulcers.

MicroRNA Expression in Chronic Venous Leg Ulcers and Implications for Wound Healing: A Scoping Review

Purpose: Chronic venous leg ulcers (CVLUs) comprise the majority of lower-extremity wounds, yet their pathophysiology is not fully understood. While research has shown that microRNAs are an important component of wound inflammation, few have explored the role of microRNAs (miRNAs) in the healing of CVLUs. This scoping review examines miRNAs in CVLUs and the association with wound healing. Methods: In December 2023, we searched MEDLINE/PubMed, Embase, Scopus, and CINAHL for studies published in 2013-2023 examining miRNAs in CVLU healing. Results: Six studies met inclusion criteria. MicroRNAs were extracted from various specimens including serum, skin biopsy samples, and adipose tissue-derived mesenchymal cells from individuals with CVLUs. Overexpression of miR-221, miR-222, miR-92a, and miR-301a-3p hindered angiogenesis, while overexpression of miR-296, miR-126, miR-378, and miR-210 facilitated angiogenesis. Overexpression of miR-34a/c, miR-301a-3p, miR-450-5p, miR-424-5p, miR-516-5p, and miR-7704 increased local inflammatory responses and inhibited keratinocytes proliferation, impairing healing, while overexpression of miR-19a/b and miR-20 downregulated keratinocytes' inflammatory response, promoting healing. Downregulation of miR-205, miR-96-5p, and miR-218-5p enhanced cellular proliferation and promoted wound healing. Downregulation of miR-17-92 was linked with impaired healing. Discussion: MicroRNAs play a role in regulating angiogenesis, inflammatory responses, and cell migration in chronic-wound healing. However, studies of miRNAs in CVLUs are limited and lack a standardized approach to measurement and quantification. Further research is warranted to elucidate the mechanisms underlying microRNA involvement in CVLU healing to better understand the pathophysiology and for the future development of targeted therapies.

Venous ulcers in Behçet syndrome

INTRODUCTION

Post-thrombotic syndrome (PTS) and stasis ulcers are late complications of deep vein thrombosis (DVT) in Behçet's syndrome (BS). We aimed to determine the clinical and histopathological characteristics, treatment modalities, and outcomes in BS patients with stasis ulcers.

METHOD

We included 63 BS patients with stasis ulcers from a total of 310 with vascular involvement, seen at a multidisciplinary center between January 2021 and July 2022. Data on demographics, clinical features, histopathology, radiology, and treatments were collected. Ulcer size, location, duration, and healing time were defined.

RESULTS

Patients' median age was 45 years, and age at vascular onset was 27 years. Except for 4 pts with only venous insufficiency, all had lower extremity DVT. Ulcers appeared a median of 3 years after vascular involvement onset and in 44 % healed imminently in a median of 6 months. At the time of evaluation in the current study, of the 63 patients with history venous ulcers, 35 (56 %) presented with active ulcers while the remaining presented with complete recovery of at least one-year duration. There were in total 202 ulcers with median ulcer size of 3 cm. 72 % were localized in the gaiter region. Histopathological examination was available for 21 pts. In 67 % (14/21), the diagnosis favored stasis dermatitis. No frank vasculitis was observed. Treatment included bed rest, local treatments, venous compression and immunosuppression. Patients received a combination of immunosuppressive agents, including biological DMARDs (75 %), non-biological DMARDs (97 %), and steroids (94 %). Despite these intensive therapies, ulcers remained unhealed in 17 %, and the recurrence rate was 73 % over a median follow-up of 16.8 years.

CONCLUSION

Leg ulcers are challenging complications of DVT in BS and represent an unmet medical need. Future studies should investigate the effectiveness of early immunosuppressive therapy, and other interventions in preventing venous ulcers and improving outcome.

Utility of venoactive compounds in post-thrombotic syndrome: A systematic review

BACKGROUND

Post-thrombotic syndrome (PTS) has been highly prevalent; over 50% of the patients develop PTS after lower extremity acute deep vein thrombosis. Venoactive compounds (VACs) have been recommended for decades for patients with chronic venous insufficiency, including PTS. The objective of our study was to perform a systematic review to determine the quality of evidence on the utility of VACs for both prevention and treatment of PTS.

METHODS

A systematic review was conducted to search the literature between January 1, 1980, and July 14, 2023, for venoactive drugs or medications, deep vein thrombosis, and PTS using PubMed, MEDLINE, life science journals, and the Cochrane Library. Only randomized controlled trials (RCTs) published in English were included in this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the revised Cochrane risk-of-bias tool for RCTs were used.

RESULTS

Ninety-four references were identified; 11 RCTs fulfilled the inclusion criteria. VACs administered were diosmin, hidrosmin/rutosides, micronized purified flavonoid fraction (MPFF), and sulodexide. The studies included a highly variable proportion of patients with PTS (8.6%-100%). Some older studies omitted details of the methodology. Two studies suggested benefit of diosmin and MPFF as adjunctive treatment to rivaroxaban in the prevention of PTS and showed low or unclear risk of bias. Evaluation of RCTs for the treatment of post-thrombotic chronic venous insufficiency found low or unclear risk of bias in 81.6% to 85.7%. All studies suggested that VACs were beneficial for PTS treatment; they improved venous symptoms, decreased edema, and helped heal venous ulcers.

CONCLUSIONS

This systematic review found that VACs had at least moderate quality of evidence in improving venous symptoms, decreasing edema, and accelerating venous ulcer healing. Two pilot RCTs of higher quality suggested the usefulness of diosmin and MPFF as adjunctive treatment to rivaroxaban therapy to reduce the incidence of PTS and improve deep vein recanalization. Because most RCTs were published over two decades ago, and several lacked the required precision in reporting, new high-quality, low-bias RCTs are needed to assess the role of specific VACs for both prevention and treatment of PTS.

Retrograde Venous Perfusion Augments Healing of Chronic Venous Leg Ulcers: A Randomized Controlled Trial

Venous leg ulcers (VLUs) cause a significant health care burden due to high health care costs, prolonged treatment, and high recurrence. Our study aims to compare between retrograde venous perfusion (RVP) combined with conventional therapy versus conventional therapy for treatment of chronic VLUs with regard to safety and efficacy. Drugs used for RVP were prostaglandin E1 (alprostadil), calcium heparin, hydrocortisone, pheniramine maleate, and lidocaine. This was a randomized controlled study conducted on 60 patients with chronic VLUs from June 2023 to June 2024. Patients were divided into two groups: RVP with conventional therapy versus conventional therapy only. Outcomes included the rate of complete ulcer closure and the percentage of healing at 6 months, ulcer-related complications, and recurrence rates. At 6 months, the RVP with conventional therapy group had a significantly higher ulcer surface area reduction, 83.7% versus 61%, p = 0.001, and a higher percentage of complete healing, 86.2% versus 44.8%, p = 0.005, as compared to the conventional therapy alone group. Similarly, time to complete healing was shorter in the RVP group at 7.8 ± 2.61 weeks versus 10.7 ± 4.31 weeks, p < 0.001. There was no significant difference in rates of wound infection between the two groups. Lower, though statistically non-significant, recurrence rates were seen within the RVP group: 8% versus 15.4%. RVP should be considered one of the adjunctive treatments for chronic VLUs. It offered positive results with regard to improved healing outcomes and reduced ulcer size. More researches are needed to confirm these conclusions.

Advances in sulodexide-based long-term anticoagulation for a myasthenia gravis patient with giant thymoma

This case report describes a geriatric male patient with myasthenia gravis (MG) secondary to giant thymoma, presenting with progressive muscle weakness and ptosis. The diagnosis of MG was confirmed through pathology, imaging, and laboratory evaluations. Considering the significant surgical risks associated with the giant thymoma, adjuvant chemotherapy was initiated. Unfortunately, 2 weeks following chemotherapy, the patient developed acute respiratory failure and sudden loss of consciousness. Emergency endotracheal intubation was performed, and he was then transferred to the intensive care unit (ICU) and treated with immunoglobulin, plasmapheresis, prednisone, and pyridostigmine. During ICU hospitalization, the patient developed severe lower limb edema accompanied by increased skin temperature, particularly on the left side. Ultrasound imaging confirmed extensive thrombosis in the left iliac and femoral veins, with thrombosis involving 50%-67% of the venous lumen. To prevent the risk of pulmonary embolism (PE), an inferior vena cava filter was implanted, and low-molecular weight heparin (LMWH) was prescribed for anticoagulation. Unfortunately, the patient later experienced intermittent melena and heparin-induced thrombocytopenia (HIT), with hemoglobin levels decreasing to 55 g/L and platelet counts decreasing to 57 × 109/L. Given the adverse events associated with LMWH, sulodexide (SDX) was substituted as a novel anticoagulant with multiple benefits, including reduced thrombosis and bleeding risk, anti-inflammatory effects, and vascular endothelium protection. SDX demonstrated excellent efficacy and safety, with no adverse effects observed during the 3-year follow-up period. In conclusion, SDX should be considered an ideal potential option for long-term anticoagulation in patients with complex conditions such as MG with both thrombotic and bleeding risks.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Pulsed electromagnetic fields modulate energy metabolism during wound healing process: an in vitro model study

BACKGROUND

Pulsed electromagnetic fields (PEMFs) therapy was extensively investigated to treat wound healing, which is a highly metabolically demanding process. However, the effect of PEMFs on energy metabolism in wound healing remains largely unexplored. Therefore, our study aims to demonstrate the role of PEMFs on energy metabolism in wound healing.

METHODS

Scratch-wound healing assay and cell viability assay were performed for the in vitro study of the effect of PEMFs on cell migration and viability. Seahorse assay was conducted for energy metabolism analysis while holo-tomographic microscopy for fine changes of L929 cells. Mitochondrial membrane potential assay and intracellular reactive oxygen species (ROS) and pH assay were performed for analyzing the changes of mitochondrial function.

RESULTS

PEMFs with specific parameter (4mT, 80 Hz) promoted cell migration and viability. Glycolysis stress and mitochondria stress test revealed that PEMFs-exposed L929 cells was highly glycolytic for energy generation. Besides, PEMFs enhanced intracellular acidification and maintained low level of intracellular ROS in L929 cells. Compared to control group, much more vesicles were generated and then transported to regions close to the nuclear in L929 cells treated with PEMFs.

CONCLUSIONS

Our major findings revealed for the first time that PEMFs induce metabolic reprogramming of fibroblast shifting from mitochondrial respiration to glycolysis, accompanied with an increase of vesicular transport, which is closely related to wound healing in vitro.

Advancements in 3D skin bioprinting: processes, bioinks, applications and sensor integration

This comprehensive review explores the multifaceted landscape of skin bioprinting, revolutionizing dermatological research. The applications of skin bioprinting utilizing techniques like extrusion-, droplet-, laser- and light-based methods, with specialized bioinks for skin biofabrication have been critically reviewed along with the intricate aspects of bioprinting hair follicles, sweat glands, and achieving skin pigmentation. Challenges remain with the need for vascularization, safety concerns, and the integration of automated processes for effective clinical translation. The review further investigates the incorporation of biosensor technologies, emphasizing their role in monitoring and enhancing the wound healing process. While highlighting the remarkable progress in the field, critical limitations and concerns are critically examined to provide a balanced perspective. This synthesis aims to guide scientists, engineers, and healthcare providers, fostering a deeper understanding of the current state, challenges, and future directions in skin bioprinting for transformative applications in tissue engineering and regenerative medicine.

"I was surprised that the veins were the cause" - The illness trajectory of people with venous leg ulcers: A qualitative study

BACKGROUND

Patients with venous leg ulcers (VLUs) often carry out inadequate self-care. Person-centered care is recommended as effective support. Understanding the illness trajectory from the patient's perspective could be a way to better understand patients' needs.

AIM

The aim was to describe the illness trajectory experienced by patients with venous leg ulcers.

METHODS

Using a qualitative approach, we conducted individual interviews with a purposive sample of 12 patients with venous leg ulcers in the wound outpatient department of a university hospital. Thematic analysis was carried out utilizing the Illness Trajectory Model as the theoretical framework.

RESULTS

8 women and 4 men with an average age of 74 years had different wound durations, recurrence rates and comorbidities. We identified six illness trajectory-relevant phases: (1) "Accident" or "mosquito bite"; (2) Experiential knowledge reaches its limits; (3) Seeking professional help; (4) Help from the wound clinic; (5) Saying goodbye to normality; (6) Managing VLU in everyday life. VLUs were often caused by accidents and initially treated by patients themselves, with medical help sought later. Over time, patients adapted to treatments like compression therapy, gained self-management (SM) skills to cope with daily life challenges.

CONCLUSION

All participants performed SM to varying degrees, but not always adequately. Insufficient awareness of the wound as a symptom and complication of a causative disease caused inadequate and ineffective wound management in many cases. Adequate SM developed primarily through learning from experience. The promotion of empirical knowledge and needs-oriented education can improve the SM of affected persons.

The provision of wound care and management in a community healthcare setting: an exploratory study

OBJECTIVE

Wound management can be costly and challenging to the health services' scarce resources. Information regarding the number of wounds in a community care setting and their associated aetiology will provide nurses and nurse managers with an insight into the specific needs of these clients with wounds and highlight areas where care or services can be improved or further developed. This research aimed to establish the prevalence and aetiology of wounds, the current delivery of wound care, wound documentation and referral pathways in an Irish community care setting.

METHOD

A retrospective chart review was carried out on all clients in the community care area who received wound care from the Public Health Nursing Service over a specified one-year period.

RESULTS

A total of 331 individuals were identified as having wounds, and nearly half presented with more than one wound, equating to 632 wounds in total (point prevalence (PP)=0.46%). A total of 56% (n=186; PP=0.14%) had leg ulcers (LUs), 18% (n=58; PP=0.04%) had pressure ulcers (PUs), 15% (n=49; PP=0.04%) had developed a diabetic foot ulcer (DFUs) and a further 11% (n=38; PP=0.03%) had wounds of other aetiologies. The mean duration of wounds was 11.37 months. Comorbidities were present in 99% (n=327) of clients with wounds, with cardiovascular disease observed in 87% (n=288) of clients and diabetes in 45% (n=148). Nursing wound-related concerns resulted in 52% (n=171) of clients receiving antibiotics, with 71% (n=121) being prescribed more than one dose. As many as 61% (n=104) of clients prescribed antibiotics did not have completed documentation to demonstrate a suspected wound infection. It was established that 16% of the Public Health Nursing Service's active caseload was made up of clients with wounds and the management of these wounds accounted for 65% of nursing time, equating to 28 full-time community nurses.

CONCLUSION

This study has identified that people with chronic (hard-to-heal) wounds often present with more than one chronic disease, which may negatively influence the wound's healing trajectory, lengthening its duration. The criteria for onward referral for suspected wound infections have been examined and resulted in large numbers of poorly documented wound assessments, leading to a high reliance on the use of oral antibiotics as commonplace for the management of hard-to-heal wounds. Hard-to-heal wounds, such as lower LUs, PUs and DFUs, are either caused or significantly affected by the presence of underlying comorbidities. Therefore, aligning the prevention and management of these burdensome wounds with National Clinical Programmes will deliver efficient, cost-effective, holistic quality care to clients in Irish community healthcare settings.

Outcomes Associated With Wound Care Nurses' Practice for the Management of Venous Leg Ulcers: A Scoping Review

INTRODUCTION

The role of the wound care nurse is identified as a key element in the management of patients with venous leg ulcers (VLUs). However, the literature offers fragmented knowledge of the outcomes associated with their practice.

AIMS

To identify, summarize, and map all available evidence based on the wound care nurses practice for the treatment of VLUs.

METHODS

A scoping review was conducted in May 2024 on PubMed, CINAHL, Scopus, and Cochrane Library databases. Observational or experimental studies related to patients affected by VLUs and cared for by wound care nurse specialists were included.

RESULTS

Of the 1562 articles reviewed, 9 studies met the inclusion criteria. The most frequently measured outcomes were clinical responses and included healing rate and ulcer recurrence. Less frequent outcomes were patient-reported and resource utilization measures.

CONCLUSION

This review indicates a general predominance of outcomes related to objective clinical responses. Future studies should broaden the types of outcomes by also including patient-reported parameters (eg, pain, quality of life, stress) in order to gain greater evidence on the impact of wound care nurse specialists in the care of patients affected by VLUs.

Polymer- and Lipid-Based Nanostructures Serving Wound Healing Applications: A Review

Management of hard-to-heal wounds often requires specialized care that surpasses the capabilities of conventional treatments. Even the most advanced commercial products lack the functionality to meet the needs of hard-to-heal wounds, especially those complicated by active infection, extreme bleeding, and chronic inflammation. The review explores how supramolecular nanovesicles and nanoparticles-such as dendrimers, micelles, polymersomes, and lipid-based nanocarriers-can be key to introducing advanced wound healing and monitoring properties to address the complex needs of hard-to-heal wounds. Their potential to enable advanced functions essential for next-generation wound healing products-such as hemostatic functions, transdermal penetration, macrophage polarization, targeted delivery, and controlled release of active pharmaceutical ingredients (antibiotics, gaseous products, anti-inflammatory drugs, growth factors)-is discussed via an extensive overview of the recent reports. These studies highlight that the integration of supramolecular systems in wound care is crucial for advancing toward a new generation of wound healing products and addressing significant gaps in current wound management practices. Current strategies and potential improvements regarding personalized therapies, transdermal delivery, and the promising critically evaluated but underexplored polymer-based nanovesicles, including polymersomes and proteinosomes, for wound healing.

Sublingual varices as predictor of factors associated with cardiovascular diseases: A systematic review with meta-analysis

OBJECTIVE

Sublingual varicose veins are variations of normality that appear more prominent during aging. The systematic review aim to investigate sublingual varicose veins frequency in patients exposed to systemic and environmental exposed factors linked to cardiovascular diseases.

METHODS

This systematic review was based on the PECO strategy, and the PubMed, Web of Science, Scopus, Embase and Grey Literature library were searched for publications examining the association between sublingual varicose veins and systemic and environmental exposed factors linked to cardiovascular diseases, such as hypertension, diabetes, smoking, and leg varices. A meta-analysis was conducted using random-effects models. This review included 11 studies with a total of 2,272 patients with sublingual varicosity and systemic exposed factors linked to cardiovascular diseases. The quality assessment was improved by Newcastle and Ottawa Scales (NOS).

RESULTS

Consistent results were observed across all systemic and environmental exposed factors linked to cardiovascular diseases subgroups. We found association between sublingual varicose veins and hypertension [p = 0.0002; 95%IC2.90 [1.66-5.06]; I2 91%); diabetics (p = 0.009; 95%IC 3.19 [1.34 - 7.62]; I2 84%); tobacco abuse (p = 0.002; 95%IC 1.97 [1.29 - 3.01]; I2 82%) and leg varicosity (p = 0.03; 95%IC 2.63 [1.08 - 6.44]; I2 95%). Seven articles received score 7, indicating good quality and four articles received moderate quality.

CONCLUSION

Patients exposed to exposed factors that affect blood vessels showed a higher prevalence of sublingual varicose veins. These findings emphasize the importance of recognizing oral signs underlying systemic diseases.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023397166.

The (dis)organization of leg ulcer care: A realist synthesis

BACKGROUND

Venous leg ulcers affect 1.5% of the UK adult population. Leg ulcers are painful, can be malodourous and are associated with poor quality of life. Leg ulcers are predominantly cared for by nurses in the community. Frequently, patients receive suboptimal treatment through unwanted variations in care and simple ulcers deteriorate to become hard-to-heal wounds. It is important to understand the current UK system of care and how nurses and patients navigate through it.

AIM

The aim of this paper was to understand how, when, for whom and in what context leg ulcers are cared for in the United Kingdom and specifically, the current system of care, the nurses' role and the patients' experience in this system of care.

DESIGN

A realist synthesis of the literature was undertaken, reported following the RAMESES publication standards: Realist syntheses.

DATA SOURCES

An iterative literature search was conducted across three recognized health collections from January 2010 to January 2022 that included descriptive studies as well as primary research.

RESULTS

73 papers were included.

CONCLUSION

In the absence of UK national guidance that recommends how leg ulcer care is organized and delivered, care is commissioned locally, with variable outcomes. Patients with venous leg ulcers would like to be looked after by knowledgeable, skilled and confident nurses, in well-equipped and staffed clinics; nurses who have the ability to make clinical judgements to alter their treatment when necessary and are empowered to refer to specialist centres when further support is required.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

This synthesis offers guidance to commissioners and providers to change how leg ulcer care is organized.

PATIENT OR PUBLIC CONTRIBUTION

The views of a patient and public group was sought at each stage of the synthesis.

Venous Insufficiency: Wound Management

PURPOSE OF REVIEW

Venous leg ulcers (VLUs) are one of the most common forms of chronic wounds and with nearly half the people having recurrent episodes, this significantly impacts a patient's quality of life. As such, VLU is a chronic disease that requires lifelong maintenance and awareness. A correct diagnosis of VLU is essential for management.

RECENT FINDINGS

VLUs can be of mixed etiology and treatment should be aimed at optimizing the underlying venous hypertension based on its cause. If there is an anatomical venous reflux contributing to the non-healing of the VLU, early treatment of incompetent veins can improve healing rates. All aspects contributing to the patient's ongoing venous hypertension should be addressed to provide appropriate treatment. This can include venous interventions but also through conservative measures. Patient education and their engagement in their own care is essential for good outcomes.

Supporting patients with venous leg ulcers in self-care monitoring: an interview study with primary health care professionals

OBJECTIVE

This study described the experiences and perceptions of how primary health care professionals (PHCPs) support patients with venous leg ulcers (VLUs) in self-care monitoring.

DESIGN

A qualitative approach with reflexive thematic analysis was used, with 24 individual qualitative open interviews.

SETTING

Primary health care clinics and community health care in four southern regions in Sweden.

SUBJECTS

Registered nurses, district nurses and nurse assistants who had experience of caring for patients with VLUs. In total, 24 interviews were conducted with PHCPs in Sweden.

RESULTS

PHCPs have a vital role in promoting patient independence and responsibility, identifying needs and adapting care strategies, while also recognising unmet needs in patients with VLUs.

CONCLUSION

PHCPs actively monitor patients' self-care and establish caring relationships. They see a need for a structured primary health care work routine for ulcer management.

Glycocalyx disruption, endothelial dysfunction and vascular remodeling as underlying mechanisms and treatment targets of chronic venous disease

The glycocalyx is an essential structural and functional component of endothelial cells. Extensive hemodynamic changes cause endothelial glycocalyx disruption and vascular dysfunction, leading to multiple arterial and venous disorders. Chronic venous disease (CVD) is a common disorder of the lower extremities with major health and socio-economic implications, but complex pathophysiology. Genetic aberrations accentuated by environmental factors, behavioral tendencies, and hormonal disturbances promote venous reflux, valve incompetence, and venous blood stasis. Increased venous hydrostatic pressure and changes in shear-stress cause glycocalyx injury, endothelial dysfunction, secretion of adhesion molecules, leukocyte recruitment/activation, and release of cytokines, chemokines, and hypoxia-inducible factor, causing smooth muscle cell switch from contractile to synthetic proliferative phenotype, imbalance in matrix metalloproteinases (MMPs), degradation of collagen and elastin, and venous tissue remodeling, leading to venous dilation and varicose veins. In the advanced stages of CVD, leukocyte infiltration of the vein wall causes progressive inflammation, fibrosis, disruption of junctional proteins, accumulation of tissue metabolites and reactive oxygen and nitrogen species, and iron deposition, leading to skin changes and venous leg ulcer (VLU). CVD management includes compression stockings, venotonics, and surgical intervention. In addition to its antithrombotic and fibrinolytic properties, literature suggests sulodexide benefits in reducing inflammation, promoting VLU healing, improving endothelial function, exhibiting venotonic properties, and inhibiting MMP-9. Understanding the role of glycocalyx, endothelial dysfunction, and vascular remodeling should help delineate the underlying mechanisms and develop improved biomarkers and targeted therapy for CVD and VLU.

Critical Analysis of Cytoplasmic Progression of Inflammatory Signaling Suggests Potential Pharmacologic Targets for Wound Healing and Fibrotic Disorders

Successful skin wound healing is dependent on an interplay between epidermal keratinocytes and dermal fibroblasts as they react to local extracellular factors (DAMPs, PAMPs, cytokines, etc.) surveyed from that environment by numerous membrane receptors (e.g., TLRs, cytokine receptors, etc.). In turn, those receptors are the start of a cytoplasmic signaling pathway where balance is key to effective healing and, as needed, cell and matrix regeneration. When directed through NF-κB, these signaling routes lead to transient responses to the benefit of initiating immune cell recruitment, cell replication, local chemokine and cytokine production, and matrix protein synthesis. The converse can also occur, where ongoing canonical NF-κB activation leads to chronic, hyper-responsive states. Here, we assess three key players, TAK1, TNFAIP3, and TNIP1, in cytoplasmic regulation of NF-κB activation, which, because of their distinctive and yet inter-related functions, either promote or limit that activation. Their balanced function is integral to successful wound healing, given their significant control over the expression of inflammation-, fibrosis-, and matrix remodeling-associated genes. Intriguingly, these three proteins have also been emphasized in dysregulated NF-κB signaling central to systemic sclerosis (SSc). Notably, diffuse SSc shares some tissue features similar to an excessive inflammatory/fibrotic wound response without eventual resolution. Taking a cue from certain instances of aberrant wound healing and SSc having some shared aspects, e.g., chronic inflammation and fibrosis, this review looks for the first time, to our knowledge, at what those pathologies might have in common regarding the cytoplasmic progression of NF-κB-mediated signaling. Additionally, while TAK1, TNFAIP3, and TNIP1 are often investigated and reported on individually, we propose them here as three proteins whose consequences of function are very highly interconnected at the signaling focus of NF-κB. We thus highlight the emerging promise for the eventual clinical benefit derived from an improved understanding of these integral signal progression modulators. Depending on the protein, its indirect or direct pharmacological regulation has been reported. Current findings support further intensive studies of these points in NF-κB regulation both for their basic function in healthy cells as well as with the goal of targeting them for translational benefit in multiple cutaneous wound healing situations, whether stemming from acute injury or a dysregulated inflammatory/fibrotic response.

Wound management, healing, and early prosthetic rehabilitation: Part 1 - A scoping review of healing and non-healing definitions

BACKGROUND

Following lower limb amputation, timely prosthetic fitting enhances mobility and quality of life. However, inconsistent definitions of surgical site healing complicate prosthesis readiness assessment and highlight the need for objective wound management measures.

OBJECTIVE

This review aimed to compile definitions of healing and non-healing provided in the literature investigating biomarkers of healing of the tissues and structures found in the residual limbs of adults with amputation.

METHODOLOGY

A scoping review was conducted following JBI and PRISMA-ScR guidance. Searches using "biomarkers," "wound healing," and "amputation" were performed on May 6, 2023, on Web of Science, Ovid MEDLINE, Ovid Embase, Scopus, Cochrane, PubMed, and CINAHL databases. Inclusion criteria were: 1) References to biomarkers and healing; 2) Residuum tissue healing; 3) Clear methodology with ethical approval; 4) Published from 2017 onwards. Articles were assessed for quality (QualSyst tool) and evidence level (JBI system).

FINDINGS

Of 3,306 articles screened, 219 met the inclusion criteria and are reviewed in this article, with 77% rated strong quality. 43% of all included sources did not define healing, while the remainder used specific criteria including epithelialization (14%), wound size reduction (28%), gradings scales (3%), scarring (1%), absence of wound complications (2%), hydroxyproline levels (0.5%), no amputation (0.5%), or neovascularization (0.5%). 84% of included sources did not provide definitions of non-healing. Studies defining non-healing used criteria like wound complications (4%), the need for operative interventions (4%), or lack of wound size reduction (1%). For 10% of included sources, healing and non-healing definitions were considered not applicable given the research content. Total percentages exceed 100% for both healing and non-healing definitions because some sources used two definition classifications, such as epithelialization and wound size reduction. The findings indicate a lack of standardized definitions irrespective of study type.

CONCLUSION

This review reveals significant gaps in current definitions of healing and non-healing, often based on superficial assessments that overlook deeper tissue healing and mechanical properties essential for prosthesis use. It emphasizes the need for comprehensive definitions incorporating biomarkers and psychosocial factors to improve wound management and post-amputation recovery.

Umbilical cord mesenchymal stem cells combined with autologous platelet-rich plasma for lower extremity venous ulcers: A case report and literature review

RATIONALE

Nonhealing ulcers are difficult to manage because they deviate from the normal wound healing process. Conventional therapy cannot achieve satisfactory therapeutic effects. To verify the effectiveness of combined treatment with human umbilical cord mesenchymal stem cells (hUMSCs) and platelet-rich plasma (PRP) for nonhealing ulcers, we studied a patient with left lower limb venous ulcer (LEVU) treated with combined injection therapy.

PATIENT CONCERNS

We present the case of a LEVU patient who has not healed for a long period of time (up to 1 year).

DIAGNOSES

LEVU was diagnosed with clinical symptoms.

INTERVENTIONS

The hUMSCs plus PRP were injected into the wound edge and base (1 µL of cells/cm2 of wound surface), 0.5 mL at each point, with a distance of approximately 1 to 3 cm between points. The injection point was determined according to the extent of wound involvement.

OUTCOMES

Seven days after hUMSC + PRP application, the wound area decreased by nearly 50%. The ulcers had almost completely healed by day 62, and no serious treatment-related toxic side effects were observed.

LESSONS

hUMSCs can improve wound healing through re-epithelialization, increased angiogenesis, and granulation tissue formation. PRP has also been suggested to promote wound healing through the secretion of various nutritional factors. The combination of hUMSCs and PRP has a mutually reinforcing effect, which may achieve a 1 + 1 > 2 effect. Therefore, the combination of hUMSCs and PRP may be a safe and effective treatment option for LEVU.

Plant-Derived Exosome-Like Nanovesicles in Chronic Wound Healing

The incidence of chronic wounds is steadily increasing each year, yet conventional treatments for chronic wounds yield unsatisfactory results. The delayed healing of chronic wounds significantly affects patient quality of life, placing a heavy burden on patients, their families, and the healthcare system. Therefore, there is an urgent need to find new treatment methods for chronic wounds. Plant-derived exosome-like nanovesicles (PELNs) may be able to accelerate chronic wound healing. PELNs possess advantages such as good accessibility (due in part to high isolation yields), low immunogenicity, and good stability. Currently, there are limited reports regarding the role of PELNs in chronic wound healing and their associated mechanisms, highlighting their novelty and the necessity for further research. This review aims to provide an overview of PELNs, discussing isolation methods, composition, and their mechanisms of action in chronic wound healing. Finally, we summarize future opportunities and challenges related to the use of PELNs for the treatment of chronic wounds, and offer some new insights and solutions.

Patients with venous leg ulcers can be managed safely in the community ----results of an observational comparison study in Singapore

AIM

To examine the healing outcomes of patients with venous leg ulcers requiring compression bandaging in community care versus tertiary care.

METHOD

This was an analytical observational cohort study. Venous leg ulcer (VLU) patients who required compression bandaging were recruited from an outpatient vascular clinic between May 2021 and August 2022. Eligible patients received two-or four-layer compression bandaging and followed up with the community care or tertiary care centre nurses. The primary outcome was the difference in the total surface area of the VLU after 12 weeks, and the secondary outcome was the patient's quality of life, as measured by the Cardiff Wound Impact Schedule (CWIS).

RESULTS

Forty-seven VLU patients were recruited; 27 received compression bandaging in the community care and 20 by the tertiary care centre. Mean age 70 years old (SD 11.04). The two most prevalent comorbidities were hypertension (51.06 %) and diabetes mellitus (38.29 %). Among those who completed follow-up (12 weeks), the median difference of the total surface area of the VLU between community-based care (p = 0.02) versus tertiary-based care (0.003) was significant. However, there was no difference in the healing status between community and tertiary-based care (p = 0.68). There was no difference in the quality of life of patients between groups.

CONCLUSION

This first tropical study comparing VLU healing outcomes between community and tertiary care found no significant difference in healing with compression bandaging by nurses in either setting. However, the small sample size and high dropout rate limit the generalizability of the findings, necessitating a larger-scale study with longer follow-up. Despite these limitations, the study is a crucial step toward improving wound care services in Singapore, and highlights the need for further research to guide future community wound care implementation.

TLC-NOSF dressings as a first-line local treatment of chronic wounds: a systematic review of clinical evidence

OBJECTIVE

Several national and international guidelines recommend lipidocolloid technology with a nano-oligosaccharide factor (TLC-NOSF) dressings (UrgoStart dressing range, Laboratoires Urgo, France) for treating patients with chronic wounds. However, these dressings are still often reported as second-line options, potentially leading to loss of opportunity for patients and additional costs for payers. This review aimed to explore the reported wound healing and patient outcomes as well as the related costs when the dressings were used as first-line treatment in patients with different types of chronic wounds.

METHOD

A systematic review of the literature was conducted. Databases (MEDLINE, Embase, Emcare, and Google Scholar) were searched up to 1 February 2024, without any language or time period limitations. Studies were eligible if the evaluated dressings had been used as a first-line treatment for chronic wounds, that is, as an integral part of the standard of care (SoC) at the patient's first presentation and/or in recent wounds. The main evaluation criteria included: wound healing rate; time to reach wound closure; change in patients' quality of life (QoL); and associated costs. The quality of evidence of the included studies was appraised using well-recognised risk-of-bias tools suitable for different study designs. A narrative synthesis describes the findings in three sections depending on the type of comparison. This report followed the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

A total of 17 studies published between 2017 and 2024 met the eligibility criteria. A comparative analysis between TLC-NOSF dressings and standard dressings, both of which were used as first-line treatment, was reported in nine studies. A comparative analysis between the use of TLC-NOSF dressings as first-line and second-line treatments was reported in eight studies, and five studies reported a systematic use of the TLC-NOSF dressing as first-line treatment without a control group. Overall, the included studies had a relatively low risk of bias for the respective types of evidence. Data of 10,191 patients of both sexes and different age groups with a total of 10,203 wounds (diabetic foot ulcers, leg ulcers, pressure injuries, and other types of chronic wounds) were included in the analysis: 7775 treated with the evaluated dressing and 2428 treated with a comparator dressing. The data suggested that using TLC-NOSF as a first-line treatment for chronic wounds consistently resulted in significantly higher healing rates, shorter healing times, and cost savings compared with standard dressings used under similar conditions. Real-life evidence confirmed the results obtained in clinical trials and economic models, within similar ranges, regardless of the settings involved or of the characteristics of the patients and wounds treated. The wound healing rates ranged around 70-80% by week 20/24 and time-to-heal was reported on average around seven weeks, with slightly longer times reported in wounds with a more severe prognosis. Furthermore, the dressings were shown to improve patient QoL, and were well tolerated and accepted, supporting a wider adoption approach.

CONCLUSION

The results of this review are aligned with the current guidelines recommending the use of TLC-NOSF dressings in the treatment of patients with chronic wounds. They support its wider implementation as a first-line treatment and as an integral part of SoC for these wounds in the daily practice of all centres involved in their management.

Clinical efficacy and safety of a silver ion-releasing foam dressing on hard-to-heal wounds: a meta-analysis

OBJECTIVE

Delayed or stalled healing in open wounds can result from persisting chronic inflammation related to infection and/or persistent bacterial colonisation and biofilm. Treatment of hard-to-heal wounds focuses on debridement and exudate management, but also on infection prevention and control. Silver dressings have been evaluated in randomised clinical trials (RCTs); this meta-analysis evaluated the efficacy and safety of a silver ion-releasing foam dressing (Biatain Ag; Coloplast A/S, Denmark) to treat hard-to-heal wounds.

METHOD

Literature databases (PubMed and Cochrane Library) were searched for studies on silver ion-releasing foam dressings in the treatment of hard-to-heal wounds. Individual patient data from four RCTs were obtained and included in the meta-analysis.

RESULTS

Findings showed that treatment with the silver ion-releasing foam dressing was associated with a significantly higher relative reduction in wound area after four (least squares-mean difference (LS-MD): -12.55%, 95% confidence interval (CI): (-15.95, -9.16); p<0.01) and six weeks of treatment (LS-MD: -11.94%, 95%CI: (-17.21, -6.68); p<0.01) compared with controls. Significant benefits were also observed for time to disappearance of odour (hazard ratio: 1.61, 95%CI: (1.31, 1.98); p<0.01), relative reduction of exudate (LS-MD: -5.15, 95%CI: (-7.36, -2.94); p<0.01), proportion of patients with periwound erythema (relative risk (RR): 0.81, 95%CI: (0.69; 0.94); p<0.01), and less pain at dressing removal (LS-MD: -0.35, 95%CI: (-0.63, -0.06); p=0.02). No differences regarding safety outcomes were identified.

CONCLUSION

This meta-analysis has demonstrated beneficial outcomes and a good tolerability profile for silver ion-releasing foam dressings in the treatment of moderate-to-highly exuding wounds with delayed healing compared with control dressings.

Venous Stasis Ulceration due to Massive Splenomegaly Causing Iliac Vein Compression From Secondary Myelofibrosis

Venous stasis ulcers are nonhealing lesions due to venous hypertension secondary to valvular dysfunction or deep venous outflow obstruction. We describe a case of a 71-year-old male with a history of polycythemia vera, secondary myelofibrosis, and massive splenomegaly up to 38 cm who presented with chronic, perimalleolar venous stasis ulcers and pain on the left lower extremity. CT showed significant compression of the left common iliac vein due to mass effect from the spleen. He was managed medically while being evaluated for partial splenic artery embolization but expired due to other chronic conditions before any intervention could be performed. Partial splenic artery embolization may be considered as a treatment option for patients with symptomatic iliac vein compression due to massive splenomegaly secondary to myelofibrosis, as long as extramedullary hematopoiesis is not compromised.

Sleep, Fatigue, and Inflammatory Biomarkers in Older Adults with Chronic Venous Leg Ulcers Receiving Intensive Outpatient Wound Care

Objective: Chronic venous ulcers are a relatively common and distressing condition that disproportionately affects older individuals. Along with multiple concomitant issues such as wound drainage, pain, and mobility impairments, individuals with chronic venous leg ulcers (CVLUs) commonly report sleep disturbances and fatigue; however, limited research has examined these symptoms in relation to inflammatory biomarkers in this population over the intensive wound care treatment trajectory. This study aimed at describing the symptoms of sleep and fatigue in older adults with CVLUs receiving intensive wound treatment with weekly debridement and exploring the relationships between these symptoms and tumor necrosis factor-alpha (TNF-α), c-reactive protein (CRP), and interleukin (IL)-6. Approach: Demographics, clinical characteristics, Pittsburgh Sleep Quality Index (PSQI) scores, Brief Fatigue Inventory (BFI), TNF-α, CRP, and IL-6 levels were collected from 84 older adults with CVLUs at three time points (baseline, week 4, and week 8). Data analysis included descriptive statistics and Bayesian estimation of associations. Results: Findings showed a consistent pattern of poor sleep quality and mild fatigue among these individuals. Lower IL-6 levels at week 4 and higher CRP levels at week 8 were linked to poor sleep quality. Higher CRP levels were linked to greater fatigue at baseline and week 8. Sleep and fatigue were correlated at all time points. Innovation and Conclusion: This study highlights the importance of clinicians evaluating sleep and fatigue in those with CVLUs. Further research is needed to validate circulating inflammatory biomarkers to enhance our understanding of sleep and fatigue's role in wound healing.

Analysis of computed tomography venography for the diagnosis and endovascular treatment of iliac venous compression syndrome with venous leg ulcers: a retrospective study

Iliac vein compression syndrome (IVCS) is a clinical condition defined as obstruction of the iliac vein caused by chronic compression imposed by various causes. Currently, the clinical role of computed tomography venography (CTV) in the diagnosis of IVCS is unclear. Accurately diagnosing IVCS using CTV may enhance the understanding of the pathological anatomy of iliac veins, which may lead to better treatment outcomes, especially for recalcitrant venous leg ulcers (VLU). We aimed to investigate diagnostic criteria, contributing clinical factors, and stenting for IVCS with VLU in this study. CTV, digital subtraction angiography (DSV), and Doppler ultrasound (DUS) data were obtained from the medical and imaging records of 62 patients. Additionally, contributing factors and stenting for IVCS were analysed. Patients (100%) had clinical, aetiological, anatomic, or pathological C6 disease. CTV reduced the procedure time and contrast medium dose and provided more information than DSV. Risk factors for IVCS with VLU included female sex (P = 0.036) and advanced age (P = 0.014). The rate of ulcer healing was lower in the IVCS group without stent implantation (P = 0.020). Significant improvements were noted in venous clinical severity scores (P < 0.001) and chronic venous insufficiency questionnaire-20 scores (P < 0.001) after stenting for IVCS with C6 ulcers. CTV provides a more accurate diagnosis than DUS and DSV and allows detection of possible causes of IVCS. Female sex and advanced age were potential contributing factors for IVCS. Satisfactory outcomes were observed with stenting in the treatment of IVCS with C6 ulcers.

Identification of High-Risk Lower Extremity Wounds Using Point-of-Care Test for Bacterial Protease Activity; A Single-Centre, Single-Blinded, Prospective Study

Clinician observation is the mainstay to determine if wound infection is present, and focuses on presence of erythema, purulence, and odour. However, non-visible bacterial protease activity can delay wound healing and lead to complications. In this study, a point-of-care test to detect the presence of bacterial protease activity (BPA, tested with Woundchek Bacterial Status test) was appraised. A total of 130 patients with lower extremity wounds were recruited in vascular and podiatry clinics, and across two time-points 182 BPA tests were conducted subsequent to initial (blinded) clinician's wound appraisal. Clinical opinion ('no infection', 'possible' or 'definite' infection) and BPA result (negative or positive test) had a moderate Kendall's tau-c rank correlation coefficient of 0.32 (P < 0.001). Binary logistic regression analysis and principal component analysis showed that infection determined by clinical opinion was significantly associated with abovementioned clinical signs and a positive BPA test. However, a positive BPA result was also significantly linked with wound severity, such as number of lesions, chronicity and size. Throughout a 12-week follow-up period, median ulcer size was larger for wounds positive for BPA test at baseline (P 0.001) and week-12 (P 0.036; both Mann-Whitney U-test) respectively. As a pilot initiative, clinical staff were allowed to act on the BPA result if they wished; in 11 out of 71 test-positive cases (15%) this happened and antimicrobial dressing was applied instead of planned standard dressing. These results show that protease-releasing bacteria may be active in ulcers that do not (yet) exhibit hallmark signs of infection, and are associated with delayed healing. Targeted point-of-care testing for bacterial protease activity may have the potential to identify and enable pro-active (antimicrobial) management of these high-risk wounds.

Infrared Thermometry and Thermography in Detecting Skin Temperature Variations to Predict Venous Leg Ulcer Reulceration: A Case Report

BACKGROUND

We aimed to determine whether monitoring skin temperature (Tsk) over recently healed venous leg ulcers (VLUs) can provide an objective approach to predicting reulceration. The cases presented in this article were part of a larger, multisite, 6-month randomized clinical trial of a cooling intervention to prevent ulcer recurrence among patients with chronic venous disease (CVD) and with recently healed VLUs.

CASES

We report a series of four patients with CVD, three experienced VLU reulceration, and one case remained free of recurrence. Assessments of recurrence likelihood is based on daily patient Tsk self-reports using a handheld infrared (IR) thermometer and clinic visits using a combination digital and long-wave IR camera. All three cases with reulceration demonstrate a persistent 2°C above baseline average Tsk increase and a "dip-and-spike" pattern from -3°C to +5°C for several days prior to reulceration. In contrast, the patient who remained free of VLU recurrence showed a stable pattern of Tsk with minimal daily fluctuations. Thermal images showed Tsk of the affected extremity is warmer compared with the contralateral limb and increased between visits when ulcers recurred.

CONCLUSION

Using IR devices to monitor Tsk among patients with CVD at risk of reulceration is an objective and reliable approach to detect changes over time. Consistent Tsk elevation over the affected area as compared to the contralateral limb and a "dip-and-spike" pattern may predict reulceration. Infrared devices showed effectiveness in detecting changes indicative of Tsk changes in recently healed leg skin over scar tissue after VLU healing.

Plasma Total Ascorbic Acid and Serum 25-Hydroxy-Vitamin-D Status in Patients with Venous Leg Ulcers: A Case-Control Study

Venous leg ulcers (VLUs) pose a significant burden on patients, health care systems, and national economies. Nutritional health is an important determinant of wound healing. Vitamin C and D levels and additional biochemical markers, C-reactive protein, and albumin in a group of patients with VLUs, were compared with a control group without VLUs. No significant difference in either nutrient marker was found with the presence, size, or duration of VLUs. Obesity was significantly more common in the VLU group, as noted in other studies. Additional controlled studies should be performed with measures of VLU size and duration to assess long-term outcomes with nutritional therapy.

Harnessing the Interactions of Wound Exudate Cells with Dressings Biomaterials for the Control and Prognosis of Healing Pathways

The global socioeconomic challenge generated by wounds requires an understanding of healing and non-healing pathways in patients. Also, the interactions occurring between the wound dressing biomaterials with cells relevant to the healing process have not been sufficiently investigated, thus neglecting the role that wound dressing composition can play in healing. Through the study of six cases of acute surgical wounds, the present work analyses the early (24 h post-surgery) interactions of biochemical and cellular components with (i) Atrauman, a device made of knitted woven synthetic polymeric fibre when used as a primary dressing, and (ii) Melolin, a hydrocolloid engineered as two layers of synthetic and cellulose non-woven fibres when used as a secondary dressing. A pathway towards healing could be observed in those cases where endoglin-expressing cells and M2 macrophages were retained by Atrauman fibres at the interface with the wound bed. On the contrary, cases where the secondary dressing Melolin absorbed these cell phenotypes in its mesh resulted in a slower or deteriorating healing process. The data obtained indicate that a subtraction of progenitor cells by Melolin may impair the healing process and that the analysis of the retrieved wound dressings for biomarkers expressed by cells relevant to wound healing may become an additional tool to determine the patient's prognosis.

Computational therapeutic repurposing of tavaborole targeting arginase-1 for venous leg ulcer

Venous leg ulcers (VLUs) pose a growing healthcare challenge due to aging, obesity, and sedentary lifestyles. Despite various treatments available, addressing the complex nature of VLUs remains difficult. In this context, this study investigates repurposing boronated drugs to inhibit arginase 1 activity for VLU treatment. The molecular docking study conducted by Schrodinger GLIDE targeted the binuclear manganese cluster of arginase 1 enzyme (2PHO). Further, the ligand-protein complex was subjected to molecular dynamic studies at 500 ns in Gromacs-2019.4. Trajectory analysis was performed using the GROMACS simulation package of protein RMSD, RMSF, RG, SASA, and H-Bond. The docking study revealed intriguing results where the tavaborole showed a better docking score (-3.957 Kcal/mol) compared to the substrate L-arginine (-3.379 Kcal/mol) and standard L-norvaline (-3.141 Kcal/mol). Tavaborole interaction with aspartic acid ultimately suggests that the drug molecule binds to the catalytic site of arginase 1, potentially influencing the enzyme's function. The dynamics study revealed the compounds' stability and compactness of the protein throughout the simulation. The RMSD, RMSF, SASA, RG, inter and intra H-bond, PCA, FEL, and MMBSA studies affirmed the ligand-protein and protein complex flexibility, compactness, binding energy, van der waals energy, and solvation dynamics. These results revealed the stability and the interaction of the ligand with the catalytic site of arginase 1 enzyme, triggering the study towards the VLU treatment.

Treating Infected Non-Healing Venous Leg Ulcers with Medical-Grade Honey: A Prospective Case Series

Venous leg ulcers (VLUs) are hard-to-heal wounds and are prone to microbial colonization. Innovative and improved therapies are thus required to resolve local infection and enhance the wound healing process. The objective of this study was to evaluate the effectiveness of medical-grade honey (MGH) for the treatment of clinically infected and non-healing VLUs. This prospective case series included nine patients with an average age of 83.4 years (range: 75-91 years) with a total of eleven VLUs, previously ineffectively treated with various products. Major risk factors for the appearance of VLUs were chronic venous insufficiency, advanced age, multiple comorbidities (particularly cardiovascular diseases), and impaired mobility. All wounds presented with local signs of infection. Upon presentation, treatment was commenced with a range of MGH-based products (L-Mesitran®). Clinical signs of infection were eliminated by MGH after 2.2 weeks on average (range: 1-4 weeks), and wounds were completely healed after 7 weeks on average (range: 3-18 weeks). No further complications or recurrences were observed. MGH has a broad-spectrum antimicrobial activity and promotes rapid healing, thus improving patients' quality of life. Moreover, MGH-based products are safe, easy to use, cost-effective, and can effectively treat VLUs alone or in combination with standard-of-care therapies.

Risk factors for recanalization of truncal veins following endoluminal ablation

BACKGROUND

Recanalization of target veins after treatment of superficial venous incompetence has clinical implications and may depend on the type of intervention. The aim of this study was to evaluate patient and procedural factors associated with truncal vein recanalization in a large study cohort using the Vascular Quality Initiative (VQI) Varicose Vein Registry.

METHODS

We performed a retrospective review using the VQI Varicose Vein Registry from 2014 to 2018. We evaluated all procedures performed for truncal venous insufficiency. Demographic data and information about treatment modality were collected. Patients were separated into recanalization and nonrecanalization groups based on the status of the treated vein at follow-up ultrasound examination. The vein was only considered recanalized if the VQI noted complete recanalization of the target vein. Univariate and multivariate comparisons were performed as appropriate.

RESULTS

A total of 10,604 procedures were performed in 7403 patients. The average age was 55.9 years and 70.3% of the patients were female. Patients with recanalization were more likely to have a history of phlebitis (P < .001) and had a higher mean body mass index (30.5 vs 32., kg/m2 ; P = .006) compared with those without recanalization. There was no difference in the use of compression therapy, anticoagulation, deep venous reflux, number of pregnancies, prior deep vein thrombosis, Venous Clinical Severity Score, and clinical-etiology-anatomy-pathophysiology between patients with and without recanalization. The number of truncal veins treated per procedure was higher in the recanalization group compared with the nonrecanalization group (2.36 vs 1.88; P = .001). After multivariate logistic regression, laser ablation was associated with higher rate of recanalization compared with radiofrequency ablation (P = .017).

CONCLUSIONS

This study is the first to use VQI based data to describe risk factors for recanalization following treatment of truncal venous reflux. The use of laser ablation for truncal veins is associated with a higher risk for recanalization compared with radiofrequency ablation. Obesity, prior phlebitis, and number of veins treated were independently associated with increased rate of recanalization.

Diagnosis and treatment of venous leg ulcers: S2k Guideline of the German Society of Phlebology and Lymphology (DGPL) e.V

This S2k guideline on venous leg ulcers was created on the initiative and under the leadership of the German Society of Phlebology and Lymphology (DGPL). The guideline group also consisted of representatives from the German Society for Phlebology and Lymphology, German Dermatological Society, German Society for General Medicine, German Society for Angiology, German Society for Vascular Surgery and Vascular Medicine, German Society for Surgery, German Society for Dermatosurgery, German Society for Wound Healing and Wound Treatment, Professional Association of Phlebologists and Lymphologists and Initiative Chronische Wunden. The aim of this guideline is to combine the different approaches and levels of knowledge of the respective professional groups on the basis of consensus, so that a basic concept for the best possible treatment of patients with venous leg ulcers can be provided. A total of 70 specific recommendations were formulated and agreed upon, divided into the subject areas of diagnostics, therapy, prevention of recurrences, and everyday challenges. The guideline thus reflects the current state of scientific knowledge and is intended to be widely used as the best available document for the treatment of patients with venous leg ulcers in everyday clinical practice.

Correlation between ABO blood type and lower extremity deep vein thrombosis in elderly patients following hip fracture

OBJECTIVE

To examine the correlation between ABO blood type and the incidence of lower extremity deep vein thrombosis (LEDVT) in elderly patients after hip fracture surgery, while identifying contributing factors to thrombogenesis.

METHODS

We conducted a retrospective analysis of 159 elderly patients with hip fractures treated at Tianjin Hospital (Affiliated Hospital of Tianjin University) from December 2021 to December 2023. The cohort was divided into two groups: those with O blood type (45 patients) and those with non-O blood types (114 patients). We analyzed clinical data and the incidence of LEDVT between the groups. Logistic regression was used to identify independent risk factors for LEDVT, and receiver operator characteristic (ROC) curve analysis evaluated the predictive efficacy of these factors.

RESULTS

The incidence of LEDVT was significantly higher in the non-O blood type group compared to the O blood type group (34.21% vs. 15.56%, P = 0.0408). Logistic regression identified high body mass index (BMI), comorbid hypertension, low platelet count (PLT), prolonged prothrombin time (PT), and non-O blood type as independent risk factors for LEDVT. The ROC curve for these predictors showed an area under the curve of 0.862, with a sensitivity of 75.22%, a specificity of 86.96%, and an accuracy of 78.62%.

CONCLUSION

ABO blood type is correlated with the occurrence of LEDVT in elderly patients' post-hip fracture. Those with non-O blood type, alongside other factors such as high BMI, hypertension, low PLT, and extended PT, are at increased risk of developing LEDVT.

Clinical outcomes of radiofrequency ablation using a radiofrequency needle device for varicose ulcer: A non-randomized controlled prospective study

OBJECTIVE

To evaluate the short-term clinical outcomes of radiofrequency ablation (RFA) using a radiofrequency (RF) needle device for varicose ulcers.

METHODS

From September 2020 to September 2021, a total of 80 patients with varicose ulcers were included in this study. Based on the different surgical methods, the patients were divided into RF group and control groups, with 40 cases in each group. In the RF group, RFA was performed using an RF needle device and foam sclerotherapy was used for superficial veins. The control group was treated with conventional high-ligation stripping. The surgical data, hospitalization data, clinical efficacy, and postoperative complications of two groups were compared. Meanwhile, the correlation between RBC, HB, HCT, and ulcer healing time was analyzed.

RESULTS

Compared to the control group, RF group had shorter surgery time, duration in the hospital, and less intraoperative bleeding (p < .05). The VCSS and CIVIQ scores in RF group were significantly higher than that in control group (p < .05). The healing time of ulcers was shorter in the RF group (x2 = 19.766, p = .000). The RF group had fewer postoperative complications. There was a positive correlation between RBC, HB, and HCT, and ulcer healing time (p < .05).

CONCLUSION

The use of the RF needle device for RFA to treat patients with varicose ulcers showed acceptable short-term clinical outcomes with less incidence of trauma, faster recovery, and fewer complications.

Comparison of two ablation procedures combined with high ligation and foam sclerotherapy and compression therapy for patients with venous leg ulcers

AIM

To compare the ablation techniques' efficacy of endovenous microwave ablation (EMA) combined with high ligation (HL), foam sclerotherapy (FS) and compression therapy (CT) and endovenous laser ablation (EVLA) combined with HL-FS-CT in the treatment of VLUs.

METHOD

301 consecutive patients with VLUs from 2013 to 2022 in a 3200-bed hospital were intervened by EMA combined with HL-FS-CT and EVLA combined with HL-FS-CT were retrospectively compared.

RESULTS

One hundred thirty-four patients underwent EMA+HL-FS-CT and 167 patients underwent EVLA+HL-FS-CT. The primary outcome of the ulcer healing time was 1.45(0.75-1.5) months and 1.86(0.5-2.5) months, respectively, in the two groups (HR for ulcer healing was 1.26, 95% CI [0.96-1.66], p = 0.097). Secondary outcomes included that no significant difference was found in ulcer recurrence and GSV recanalization and complications between the two groups, and the postoperative VCSS and AVVQ were significantly lower than the baseline values in the respective groups (p = 0.0001).

CONCLUSION

EMA+HL-FS-CT and EVLA+HL-FS-CT are both effective at treating VLUs. Both of the two comprehensive treatments were beneficial to the healing of ulcers, but no evidence showed which one was superior in the ulcer healing time.

Hydrogel dressings for diabetic foot ulcer: A systematic review and meta-analysis

AIM

To investigate the differences in utility between conventional dressings and hydrogel dressings for the treatment of diabetic foot ulcer (DFU).

METHODS

The PubMed, Embase, Cochrane Library, CNKI, VIP and Wanfang databases were systematically searched up to 21 January 2023. Fixed/random-effect models were used to calculate the odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) for the effect size analysis, with heterogeneity determined by I2 statistics. Subgroup analyses of different classes of hydrogel were also conducted.

RESULTS

A total of 15 randomized controlled trials with 872 patients were eligible for the present analysis. Compared with conventional dressings, hydrogel dressings significantly improved the healing rate (OR 4.09, 95% CI 2.83 to 5.91), shortened the healing time (MD -11.38, 95% CI -13.11 to -9.66), enhanced granulation formation (MD -3.60, 95% CI -4.21 to -3.00) and epithelial formation (MD -2.82, 95% CI -3.19 to -2.46), and reduced the incidence of bacterial infection (OR 0.10, 95% CI 0.05 to 0.18).

CONCLUSION

The meta-analysis showed that hydrogel dressings are more effective in treating DFU compared with conventional dressings.

Management of post-Mohs surgical wounds with a hypothermically stored amniotic membrane: a case series

OBJECTIVE

The aim of this case series is to present an alternative approach to managing post-Mohs Micrographic Surgery (Mohs) wounds with hypothermically stored amniotic membrane (HSAM).

METHOD

A case series of patients with post-Mohs wounds is presented, with four patients referred for hard-to-heal wounds following a Mohs procedure that was performed 1-3 months previously. All wounds underwent weekly assessment, debridement, and application of HSAM and secondary dressings. Treatment also included management of bioburden, proper skin care and compression therapy for lower extremity wounds.

RESULTS

This case series of seven wounds consisted of four females and three males with a mean age of 87.6 years. Mean wound size at first application of HSAM was 1.34±1.20cm2. All wounds closed, with an average time to wound closure of 43.7±27.1 days. Patients received an average of 4.6±2.5 HSAM applications. The four post-Mohs wounds with a history of being hard-to-heal had an average time to wound closure of 35.5±16.3 days, with an average duration of 86.5±32.4 days prior to the first HSAM application.

CONCLUSION

The results of this case series suggest that use of HSAM may provide an alternative approach to managing post-Mohs wounds. In addition, these findings suggest that HSAM may be of greatest benefit when applied early after Mohs surgery.

Host-Microbiome Crosstalk in Chronic Wound Healing

The pathogenesis of chronic wounds (CW) involves a multifaceted interplay of biochemical, immunological, hematological, and microbiological interactions. Biofilm development is a significant virulence trait which enhances microbial survival and pathogenicity and has various implications on the development and management of CW. Biofilms induce a prolonged suboptimal inflammation in the wound microenvironment, associated with delayed healing. The composition of wound fluid (WF) adds more complexity to the subject, with proven pro-inflammatory properties and an intricate crosstalk among cytokines, chemokines, microRNAs, proteases, growth factors, and ECM components. One approach to achieve information on the mechanisms of disease progression and therapeutic response is the use of multiple high-throughput 'OMIC' modalities (genomic, proteomic, lipidomic, metabolomic assays), facilitating the discovery of potential biomarkers for wound healing, which may represent a breakthrough in this field and a major help in addressing delayed wound healing. In this review article, we aim to summarize the current progress achieved in host-microbiome crosstalk in the spectrum of CW healing and highlight future innovative strategies to boost the host immune response against infections, focusing on the interaction between pathogens and their hosts (for instance, by harnessing microorganisms like probiotics), which may serve as the prospective advancement of vaccines and treatments against infections.

Pinch Grafting: A Systematic Review of Modern Perspectives and Applications in Dermatologic Surgery and Wound Healing

BACKGROUND

Pinch grafting has experienced a resurgence in interest in recent years, stemming from its simplicity, safety, and potential in restoring tissue integrity. While historically employed for chronic nonhealing wounds, pinch grafts have shown promise following surgical procedures, particularly those involving the lower extremities.

OBJECTIVE

To systematically review the literature and present an updated overview of the current applications of pinch grafting.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In collaboration with a medical reference librarian, the PubMed, Embase, Scopus, and Web of Science databases were searched for studies reporting on the use of pinch grafting from 2000 onward. The references of each included article were also screened.

RESULTS

Ten articles met final inclusion criteria. In total, 300 patients underwent pinch grafting for treatment of skin ulceration, while an additional 35 cases were performed as an alternative to primary closure following skin cancer resection. Overall, pinch grafting was safe and well tolerated, with minimal adverse outcomes reported.

CONCLUSION

Pinch grafting is a safe, straightforward, and effective technique to promote the healing of chronic wounds. While the procedure shows early promise in emerging applications within dermatologic surgery, only about 10% of the reported cases involved this indication, reflecting a need for further research in this area.

Effects of electromagnetic therapy in treating patients with venous leg ulcers: An overview of systematic reviews

This study aims to evaluate the effects of electromagnetic therapy (EMT) on the treatment of venous leg ulcers (VLUs) by synthesising and appraising available meta-analyses (MAs) and systematic reviews (SRs). A comprehensive literature search was conducted across major databases up to 10 January 2024, focusing on SRs/MAs that investigated the use of EMT for VLUs. Selection criteria followed the PICO framework, and dual-author extraction was used for accuracy. Quality assessment tools included AMSTAR2, ROBIS, PRISMA, and GRADE. The search yielded five eligible studies. The reviews collectively presented moderate methodological quality and a low risk of bias in several domains. Reporting quality was high, albeit with inconsistencies in fulfilling certain PRISMA checklist items. The evidence quality, primarily downgraded due to small sample sizes, was rated as moderate. Whilst some studies suggest potential benefits of EMT in the treatment of VLUs, the overall evidence is inconclusive due to methodological limitations and limited sample sizes. This review underscores the need for future research with more rigorous methodologies and larger cohorts to provide clearer insights into the efficacy of EMT for VLUs.

Comparison of the therapeutic efficacy of magneto-LED therapy and magnetostimulation applied as the adjuvant treatment of venous leg ulcers - preliminary study

PURPOSE

Venous leg ulcers are chronic wounds that are difficult to cure. The aim of the study was to compare the therapeutic efficacy of two methods of physical medicine - magneto-LED therapy and magnetostimulation, applied as adjuvant treatment in the treatment of venous leg ulcers.

METHODS

The study included 81 patients, 37 male (45.6%) and 44 female (54.3%) ones, age range between 45 and 90 years, with venous leg ulcers. The patients were assigned to two study groups: magneto-LED therapy (group 1) or magnetostimulation (group 2). In both groups, a total of 40 daily procedures were performed. Wound healing was evaluated using computerized planimetry and the pain intensity on numeric rating scale.

RESULTS

After treatment, the decrease in healing rate in group 1 was statistically significantly higher in comparison to group 2 (p < 0.001), while a statistically significant reduction in the surface area of ulcers was obtained, amounting on the average from 6.34 ± 1.29 cm2 to 2.31 ± 1.25 cm2 in group 1 (p < 0.001), and from 6.52 ± 1.20 cm2 to 4.79 ± 1.17 cm2 in group 2 (p < 0.001). The percentage changes of ulcers area in group 1 (64.21 ± 17.94%) were statistically significantly greater as compared to group 2 (25.87 ± 14.07%) (p < 0.001). After treatment, the decrease in pain relief in group 1 was statistically significantly higher in comparison to group 2 (p = 0.006), while pain intensity after treatment decreased statistically significantly in both compared groups of patients (p < 0.001).

CONCLUSIONS

Magneto-LED therapy and magnetostimulation caused significant reduction of surface area of the treated venous leg ulcers and pain intensity, yet magneto-LED therapy was more efficient. Both evaluated methods also significantly reduced pain intensity.

Neutralizing Staphylococcus aureus PAMPs that Trigger Cytokine Release from THP-1 Monocytes

Innate immunity has considerable specificity and can discriminate between individual species of microbes. In this regard, pathogens are "seen" as dangerous to the host and elicit an inflammatory response capable of destroying the microbes. This immune discrimination is achieved by toll-like receptors on host cells recognizing pathogens, such as Staphylococcus aureus, and microbe-specific pathogen-associated molecular pattern (PAMP) molecules, such as lipoteichoic acid (LTA). PAMPs impede wound healing by lengthening the inflammatory phase of healing and contributing to the development of chronic wounds. Preventing PAMPs from triggering the release of inflammatory cytokines will counteract the dysregulation of inflammation. Here, we use ELISA to evaluate the use of cationic molecules branched polyethylenimine (BPEI), PEGylated BPEI (PEG-BPEI), and polymyxin-B to neutralize anionic LTA and lower levels of TNF-α cytokine release from human THP-1 monocytes in a concentration-dependent manner. Additional data collected with qPCR shows that BPEI and PEG-BPEI reduce the expression profile of the TNF-α gene. Similar effects are observed for the neutralization of whole-cell S. aureus bacteria. In vitro cytotoxicity data demonstrate that PEGylation lowers the toxicity of PEG-BPEI (IC50 = 2661 μm) compared to BPEI (IC50 = 853 μM) and that both compounds are orders of magnitude less toxic than the cationic antibiotic polymyxin-B (IC50 = 79 μM). Additionally, the LTA neutralization ability of polymyxin-B is less effective than BPEI or PEG-BPEI. These properties of BPEI and PEG-BPEI expand their utility beyond disabling antibiotic resistance mechanisms and disrupting S. aureus biofilms, providing additional justification for developing these agents as wound healing therapeutics. The multiple mechanisms of action for BPEI and PEG-BPEI are superior to current wound treatment strategies that have a single modality.